以水平面转为主的先天性眼球震颤混合性代偿头位的手术治疗

目的探讨治疗以水平面转为主的先天性眼球震颤混合型代偿头位的手术矫正方法。设计回顾性病例系列。研究对象2003—2008年在河北省邢台眼科医院接受治疗的以水平面转为主的先天性眼球震颤混合型代偿头位的患者11例。方法采用后退双眼慢相侧的一对配偶肌（内直肌后退6mm,外直肌后退8mm）,同时加强快相侧的一对配偶肌（外直肌缩短9mm,内直肌缩短7ram）的手术方法。术后随访6—20个月。主要指标双眼正前方注视视力,水平面转、下颌上抬或内收、头倾的程度。结果术后最后一次随访时双眼正前方注视最佳矫正视力提高均≥2行。术后混合型代偿头位完全消失或≤100者9／11例,其中1例头位过矫。代偿头位扭转角≤15。者1例,仍残留25。水平面转头位者1例。结论通过单纯的减弱和加强水平肌肉的后退缩短手术进行中间带移位即可明显改善水平面转为主的先天性眼球震颤的混合性代偿头位,并能提高正前方双眼视力。（眼科,2009,18：275—278）     

先天性水平冲动型眼球震颤的手术治疗

目的探讨先天性水平冲动型眼球震颤的手术方法及效果。方法回顾性分析经手术治疗的先天性水平冲动型眼球震颤8例患者临床资料,所有患者均根据中间带位置,代偿头位进行中间带移位。结果 6例代偿头位消失,1例术后残留10°扭转角,1例术后残留15°扭转角。所有患者原在位视力均提高。结论通过中间带移位,可以明显改善先天性水平冲动型眼球震颤的代偿头位及外观,并能提高第一眼位的双眼视力。     

手术治疗伴有斜视的先天性冲动型眼球震颤

目的探讨先天性冲动型眼球震颤合并斜视的手术治疗方法及效果。方法回顾性分析行手术治疗的先天性冲动型眼球震颤伴有斜视11例,所有患者均根据中间带位置、代偿头位、斜视角度和注视眼的关系进行中间带的移位以及斜视的矫正。结果9例术后代偿头位完全改善,1例术后残留15°面转角,1例残留10°上斜视,所有患者原在位视力均提高两行以上。结论通过中间带移位及斜视度叠加矫正斜视,可以明显改善先天性冲动型眼球震颤的代偿头位及外观,并能提高第一眼位的双眼视力。     

先天性特发性眼球震颤Parks法手术前后的立体视觉

目的:观察先天性特发性眼球震颤儿童Parks中间带移位术前后的立体视觉。方法:利用同视机图片和立体图本,检查12例先天性眼球震颤儿童术前和术后6mo正前方远、近距离立体视觉。结果:所有患者术后正前方眼球基本不震颤或明显减轻,12例患儿中7例代偿头位消失,获得立体视觉,5例术后代偿头位改善,其中3例建立同时视觉,但未建立立体视觉。结论:Parks法中间带移位术治疗先天性特发性眼球震颤,不仅能消除和减轻代偿头位与眼球震颤,提高视力,代偿头位消失的患者还能建立远、近立体视觉,提高视觉质量。     

先天性特发眼球震颤合并斜视手术治疗的研究

目的 探讨先天性特发眼球震颤(CIN)合并斜视手术设计方案及手术疗效.设计回顾性病例系列.研究对象66例先天性眼球震颤合并斜视患者,其中合并共同性内斜视22例,内斜视V征5例,共同性外斜视5例,外斜视A征4例,间歇性外斜视3例,麻痹性斜视11例,眼球后退综合征2例,垂直分离性斜视3例,Helveston综合征1例.方法 手术方式设计综合考虑患者的双眼视的状态、注视眼、视力是否平衡、麻痹性斜视的代偿头位和眼球震颤中间带的代偿头位,在改善代偿头位的基础上矫正斜视.主要指标代偿头位扭转角,第一眼位的双眼视力.结果 手术后随访3～12个月,平均6个月.术后头位消失占70.8%,明显改善占29.2%;在第一眼位术后视功能获得改善的患者占89.3%.结论 合并有斜视的先天性特发眼球震颤的手术治疗既要解决斜视问题也要解决代偿头位.合理的手术设计是获得较好结果的前提.(眼科,2009,18:55-58)     

先天性眼球震颤的手术治疗及对比敏感度在疗效评价中的作用

目的研究改良Park术及眼外肌本体感受器切除联合眼外肌缩短术在治疗先天性眼球震颤中的疗效及对比敏感度检查在评价眼球震颤手术疗效中的作用。方法将82例先天性眼球震颤患者分为有中间带型(40例)和无中间带型(42例)两组。有中间带型眼球震颤患者施行改良的Park术,无中间带型眼球震颤患者施行眼外肌本体感受器切除联合眼外肌缩短术。所有患者术前及术后1个月给予双眼矫正视力及对比敏感度检查。结果所有患者术后眼位均为正位,且眼球转动各方向均不受限。40例有中间带型先天性眼球震颤患者术后1个月异常头位消失,第一眼位视力均较术前明显提高(P<0.05),均提高≥2行;对比敏感度在3周/度(cycle/degree,c·d-1)、6c·d-1、12c·d-1、18c·d-1空间频率下均较术前明显提高(均为P<0.05)。42例无中间带型先天性眼球震颤患者中,仅有7例患者双眼视力在术后1个月时提高≥2行(16.7%),但共有38例(90.5%)患者对比敏感度在各个空间频率上均较术前提高(均为P<0.05)。结论在改善先天性眼球震颤患者的异常头位及视功能方面,改良Park术与眼外肌本体感受器联合眼外肌缩短术具有良好的治疗效果;对比敏感度检查可用于客观评价先天性眼球震颤手术的效果。     

存在两个中间带的先天性冲动性眼球震颤4例报告

先天性冲动性眼球震颤常采取代偿头位，使双眼震颤强度最轻或消失，从而可获得最佳视力，此位置称为中间带。国内外眼科医生采用中间带移位手术来改善或消除代偿头位，收到较好的效果。而合并两个中间带的先天性冲动性眼球震颤临床较少见，国内天津眼科医院率先提出了存在两个相反方向中间带的治疗方案。我院于1999年10月至2004年6月间收治4例存在两个中间带的先天性冲动性眼球震颤患者，其中2例采用了天津眼科医院的治疗方案，另2例较特殊，未行手术治疗，现报告如下。     

先天性特发性眼球震颤合并水平斜视的手术治疗

目的:探讨先天性特发性眼球震颤合并水平斜视的手术治疗方法。方法:对27例合并水平斜视的先天性特发性眼球震颤患者,采用主导眼中间带移位术联合斜视眼斜视矫正术。结果:在27例患者中,所有患者主导眼第1眼位视力均提高2行以上,22例代偿头位消失,明显改善5例,术后25例患者眼位映光基本正位(±5°以内),2例患者眼位映光在±5°～±10°,部分患者双眼视功能较术前有所好转。结论:对合并水平斜视的先天性特发性眼球震颤行主导眼中间带移位术联合斜视眼斜视矫正术,不仅能改善原在位视力,矫正代偿头位和斜视,还有利于双眼视的建立。     

存在两个反方向中间带的先天性冲动性眼球震颤的治疗研究

目的 探讨治疗存在两个反方向中间带的先天性冲动性眼球震颤的有效方法。方法 对14例存在两个反方向中间带的先天性冲动性眼球震颤患者,采用三棱镜中和两侧代偿头位扭转角的方法确定两个中间带中起主导作用的中间带后,配戴三棱镜;对代偿头位改善且不转向对侧者;设计并实施中间带移位手术。结果 采用此方法治疗的14例患者中,1次手术成功者10例,2次手术成功者2例,1次手术后配戴三棱镜症状缓解者2例;全部患者正前方注视视力均提高。结论 手术前确定两个中间带中起主导作用的中间带;配戴三棱镜后确定代偿头位改善且不转向对侧,是行中间带移位手术治疗存在两个反方向中间带的先天性冲动性眼球震颤成功的关键。该方法疗效可靠、可供临床推广使用。     

双眼内直肌后退术治疗眼球震颤阻滞综合征

目的探讨内直肌后退术治疗眼球震颤阻滞综合征。方法8例眼球震颤阻滞综合征患者行双眼内直肌后退术,并随访一年。结果8例患者中,5例患者随访满1年时眼位保持正位,3例随访初期眼位保持正位,半年时眼位轻度回退。所有患者眼球震颤症状均无改善。结论眼球震颤阻滞综合征患者的内斜视通过双眼内直肌后退术可获得改善,但手术量有待进一步探索。     

Surgery for the treatment of vertical head posturing associated with infantile nystagmus syndrome: results in 24 patients

Background: The study of the clinical and electrophysiological effects of eye muscle surgery on patients with infantile nystagmus has broadened our knowledge of the disease and its interventions. Design: Prospective, comparative, interventional case series. Participants: Twenty‐four patients with a vertical head posture because of electrophysiologically diagnosed infantile nystagmus syndrome. The ages ranged from 2.5 to 38 years and follow up averaged 14.0 months. Methods: Thirteen patients with a chin‐down posture had a bilateral superior rectus recession, inferior oblique myectomy and a horizontal rectus recession or tenotomy. Those 11 with a chin‐up posture had a bilateral superior oblique tenectomy, inferior rectus recession and a horizontal rectus recession or tenotomy. Main Outcome Measures: Outcome measures included: demography, eye/systemic conditions and preoperative and postoperative; binocular, best optically corrected, null zone acuity, head posture, null zone foveation time and nystagmus waveform changes. Results: Associated conditions were strabismus in 66%, ametropia in 96%, amblyopia in 46% and optic nerve, foveal dysplasia or albinism in 54%. Null zone acuity increased at least 0.1 logMAR in 20 patients (P < 0.05 group mean change). Patients had significant (P < 0.05) improvements in degrees of head posture, average foveation time in milliseconds and infantile nystagmus syndrome waveform improvements. Conclusions: This study illustrates a successful surgical approach to treatment and provides expectations of ocular motor and visual results after vertical head posture surgery because of an eccentric gaze null in patients with infantile nystagmus syndrome.     

Surgical management of congenital nystagmus

Forty-three patients with congenital nystagmus who underwent surgery in the Ocular Motility Clinic at The Royal Victorian Eye and Ear Hospital, Melbourne, are analysed to assess the effect of different surgical approaches on the abnormal head posture and binocular visual performance. There were 38 patients with a horizontal head turn, and five with a vertical abnormal head posture. In those undergoing horizontal nystagmus surgery the different surgical procedures have been classified as: Anderson procedure, which involves large bilateral augmented recessions only; Kestenbaum and augmented Kestenbaum bilateral recess/resect surgery in which the recess:resect ratio is less than 1; and a modified Anderson-Kestenbaum procedure with the emphasis on large recessions, so that the bilateral recess/resect ratio is greater than 1. In this series the augmented recessions of the Anderson and Anderson-Kestenbaum procedures appeared to produce a more favourable result of improved binocular vision. The five patients with vertical abnormal head posture with nystagmus had various surgical procedures with very encouraging results, both in terms of reduction of the abnormal head posture and an even greater improvement of binocular vision than with the horizontal cases. The surgical techniques in these cases are presented and discussed.     

SURGICAL MANAGEMENT OF CONGENITAL NYSTAGMUS

Forty-three patients with congenital nystagmus who underwent surgery in the Ocular Motility Clinic at The Royal Victorian Eye and Ear Hospitar Melbourne, are analysed to assess the effect of different surgical approaches on the abnormal head posture and binocular visual performance. There were 38 patients with a horizontal head turn, and five with a vertical abnormal head posture. In those undergoing horizontal nystagmus surgery the different surgical procedures have been classified as (4 Anderson procedure, which involves large bilateral augmented recessions only; (ii) Kestenbaum and augmented Kestenbaum bilateral recess/resect surgery in which the recess:resect ratio is less than 1; and (iii) a modified Anderson-Kestenbaum procedure with the emphasis on large recessions. so that the bilateral recess/resect ratio is greater than 1. In this series the augmented recessions of the Anderson and Anderson-Kestenbaum procedures appeared to produce a more favourable result of improved binocular vision. The five patients with vertical abnormal head posture with nystagmus had various surgical procedures with very encouraging results, both in terms of reduction of the abnormal head posture and an even greater improvement of binocular vision than with the horizontal cases. The surgical techniques in these cases are presented and discussed.     

The effect of bilateral horizontal rectus recession on visual acuity, ocular deviation or head posture in patients with nystagmus.

PURPOSE: This work was undertaken to evaluate the effect of bilateral horizontal rectus recession on visual acuity, ocular deviation and head posture in patients with nystagmus. METHODS: Twenty patients underwent recession of 4 horizontal rectus muscles to dampen the nystagmus. At least 2 muscles were recessed posterior to the equator. RESULTS: Monocular and binocular visual acuity improved from 1 to 3 Snellen lines after the procedure in 13 patients (76.5%). Visual changes in log MAR notations were statistically significant with Wilcoxon analysis in each and both eyes. Preoperative binocular visual acuity was 0.73 +/- 0.26 log MAR that reached to 0.62 +/- 0.32 log MAR after surgery (P = 0.02). The greatest improvement was observed in patients with congenital motor nystagmus. Ten patients had horizontal strabismus in addition to nystagmus before the surgery. One-millimeter additional recession of both medial rectus muscles caused an average reduction of 6 PD in esotropia. Corresponding figures for similar additional recessions of the lateral rectus muscles was 11 PD for correction of exotropia. Abnormal head posture decreased in all the cases and improved completely in most of them. CONCLUSIONS: Large horizontal rectus recession can improve visual acuity and decrease nystagmus in sensory and motor types. By revision in surgical planning, strabismus and abnormal head posture can also be corrected.     

Survey of management strategies for nystagmus patients with vertical or torsional head posture

Surgery for a horizontal face turn or tilt in patients with congenital nystagmus began in 1953 and has been modified frequently since then. There are few published reports stating the frequency of or surgical guidelines for the treatment of a vertical or torsional head position due to congenital nystagmus and associated null point. To address this issue a questionnaire was sent to all members of the American Association for Pediatric Ophthalmology and Strabismus. Most respondents see one or two cases of vertical head posture yearly and use observation as their primary therapy. When surgery is indicated, a graded bilateral vertical rectus recession or combined vertical rectus recession-resection procedure are usually done. Most respondents see no cases of torsional head posture yearly, and an overwhelming majority observe these patients. No one surgical procedure was advocated by most of the responding surgeons.     

Superior oblique tendon expanders with inferior rectus recessions for chin-up null point nystagmus.

Three patients with chin-up head postures caused by a nystagmus null point in downgaze were treated using bilateral superior oblique tendon expanders and inferior rectus muscle recessions. Preoperative chin-up head postures measured from 25 to 45 degrees. Postoperatively, 2 patients had complete resolution of their abnormal vertical head postures, and the third showed improvement.     

Understanding ocular torticollis in children

Ocular abnormal head posture (AHP) or torticollis is a frequent sign in pediatric pathology The incidence is 5.6% in ophthalmological practice and 3.19% in pediatric ophthalmological practice. The abnormal head posture is adopted to improve visual acuity maintain binocular single vision, center residual visual field with the body or for cosmetic reasons. Face turn is the most frequent abnormal head posture in pediatric ophthalmology. The more common diseases causing face turn are Duane syndrome, congenital fibrosis of extraocular muscles, nystagmus, refractive errors, visual field defects. The most frequent ocular causes of head tilt in children are congenital nystagmus, superior oblique paresis, dissociated vertical deviation, Brown syndrome, refractive errors. Chin-up or chin-down abnormal head postures are most commonly caused by "A" and "V"-pattern strabismus, palpebral ptosis, nystagmus, refractive errors. Torticollis is not a diagnosis, but it is a sign of an underlying disease. There are ocular diseases which diagnosis is straightforward for general practitioner, pediatricians or pediatric surgeons (horizontal nystagmus, lateral rectus paralysis, ptosis, esotropia), but others less obvious (superior oblique paralysis, Duane syndrome, A and V-pattern strabismus, torsional nystagmus) because of the compensatory head posture, and these last disorders are predisposed to confusion with congenital AHP Interdisciplinary collaboration between ophthalmologist, pediatrician, pediatric surgeon, ENT specialist and neurologist is mandatory in establishing the etiology of AHP Every child with AHP must be examined by an ophthalmologist.     

Combined bilateral superior rectus muscle recession and inferior oblique muscle weakening for dissociated vertical deviation.

PURPOSE: Dissociated vertical deviation (DVD) is a common disorder that is often difficult to treat satisfactorily with extraocular muscle surgery. Weakening both elevators in a single eye is uncommonly performed because of possible severe upgaze deficiency or chin-up head posture postoperatively. METHODS: A retrospective review of medical records was performed that yielded 14 patients who had undergone bilateral superior rectus muscle recessions (mean 8.1 mm, range 5-10 mm) and bilateral inferior oblique muscle recession, myectomy, or anterior transposition in the treatment of DVD. Three additional patients with asymmetric inferior oblique muscle overaction or true hypertropia in primary gaze position were identified who had bilateral superior rectus muscle recessions combined with unilateral inferior oblique muscle weakening. RESULTS: Mild-to-moderate elevation deficiencies were common postoperatively but never exceeded -2 up-gaze limitation (scale 0 to -4) except in the immediate postoperative period and were not associated with persistent chin-up head posturing. Cosmetically objectionable upper eyelid retraction occurred in one patient after re-recession of a superior rectus muscle but before inferior oblique muscle surgery. Only three patients undergoing four vertical muscle surgeries had residual DVD >10 PD in primary gaze position, and none exhibited manifest dissociated strabismus warranting further treatment. CONCLUSION: Bilateral superior rectus muscle recession of up to 10 mm combined with inferior oblique muscle weakening appears to be a safe surgical approach in the management of patients with large angle or recurrent DVD. Our data further suggest that simultaneous four vertical muscle surgery may be preferred in some patients to weakening the superior rectus or inferior oblique muscles alone.